LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF NURSING

NAME: APOLONIO, REYJAN BORJA, ARMIE JANE

DAUZ, ABEGAIL PALAGANAS, KYFER
PILAPIL, RHONA RHEZ RAFAEL, KYRA
ROVILLOS, JOANNA SORIANO, ALEXANDRA
UNTALAN, FERLIE VIDEZ, JERAMIL

YEAR/SECTION: IIBSN-2D

Case Scenario:

A group of preschool-aged children play on the school playground when suddenly Kiara, a 5-year-old child fall on the ground and hurt herself. The other children
go near her and worry about her condition, they called the attention of the school nurse who is nearby. The school nurse assesses Kiara and observes for any injuries.
Kiara cries and shows to the school nurse her knees with bruises and abrasion. She asks the school nurse “Ms. Nurse, what will happen to me? I am afraid of any
wounds and blood. Please help me.” What will be the plan of care for Kiara?
 LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING

NURSING CARE PLAN (NCP)

Assessment Plannin Implementation Rationale Evaluation

g
Problem:
Short Term Goal : Short term Goal:
A 5-year-old child fall in 1. Observe the severity of the 1. To know the necessary and
the ground and hurt  After nursing abrasions and assess pain scale. appropriate intervention. Pain  After 1 hour of nursing
herself. interventions, the threshold also varies because she intervention, Patient will be able
patient will relate is still a child. to tolerate the pain of bruises
Subjective: the intent to use and abrasions will reduce the
safety measures to 2. Clean the wound immediately,stop 2. For infection control measure. pain. GOAL MET.
“Ms. Nurse, what will prevent falls. the bleeding and maintain bacterial
happen to me? I am afraid balance-use aseptic technique
of any wounds and blood. Long – Term Goal when performing wound Long term Goal:
Please help me” as procedures, ( handwashing, using
verbalized by the child.  After nursing a sterile field, sterile  After 2 days of nursing
interventions, the instruments,sterile dressings). intervention, Patient will result
Objective: patient will from free infection of abrasions
demonstrate 3. Cover the wound with bandage. 3. To prevent infection and prevents and it will dry, bruises will fade
Knees with selective healing process from being and it will be back to normal.
bruises and prevention disrupted. Goal met.
abrasion. measures and will
implement
Nursing Diagnosis: strategies to
increase and 4. Talk to her while cleaning the 4. This will help to ease and reduce
Mild anxiety related to fear prevent falls when wound and treating the wound,like the child’s fear and trust will be
of wounds and blood as playing. asking her favorite color and her gained. It will also divert her
evidenced by patient favorite song anything that she attention, while treatment is being
verbalization. could relate with. provided.

5. Assess the child in other parts of 5. To monitor any injuries from falling
 LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING

the body, aside from the bruises
and abrasions on the knee.Like
asking her if she hurt her head
from the fall, or any other parts of
her body.
to the ground,to prevent any
injuries from the fall that could lead
to worse case scenario.

6. Educate the child about 6. Preschool- age is a good time to

safety,including safety with types of educate the children about their
play. safety.

7. Educate and encourage the child 7. Preschoolers are magical thinkers,

about some examples of giving them an idea about a type of
cooperative play. Like playing with play could establish and be their
puzzles, sand building. guide.

Dependent Nursing Intervention: Dependent Nursing Intervention:

1. Administer medications as 1. To help relieve the pain.

ordered.

Collaborative Nursing Intervention: Collaborative Nursing Intervention:

1. 1.
LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING